Proceedings of the Subcommittee on
Veterans Affairs
Issue 5 - Evidence (April 24 meeting)
OTTAWA, Wednesday, April 24, 2002
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day at 5:45 p.m. to examine and report on the health care provided to veterans of war and of peacekeeping missions; the implementation of the recommendations made in its previous reports on such matters; and the terms of service, post-discharge benefits and health care of members of the regular and reserve forces as well as members of the RCMP and of civilians who have served in close support of uniformed peacekeepers.
Senator Michael A. Meighen (Chairman) in the Chair.
[English]
The Chairman: We appreciate very much, General Couture, that you found the time to be with us this evening and to bring Colonel Cameron, who was at our hearing last Wednesday, and Major Grenier. All of you have some considerable expertise to bring to bear on the subject of our immediate interest.
Lieutenant-General Christian Couture, Assistant Deputy Minister (Human Resources — Military), Department of National Defence: First, thank you for inviting me, along with my colleagues, Colonel Cameron on my left, and Major Grenier on my right.
I will say a few words about the subject of post-traumatic stress disorder, known as PTSD, probably the most well- known operational distress injury.
We have previously provided the committee with several fact sheets on PTSD and our initiatives, as well as a copy of my remarks to the House committee. Therefore, I would like to begin with a few comments to highlight the ongoing work within the Canadian Forces, and then, with your permission, I will ask Colonel Cameron to say a few words on PTSD, from a medical practitioner point of view, that will establish the facts about this injury.
As you are aware, over the past few years, we have concentrated on quality of life improvements for our personnel. We have been undertaking serious reform of our health care system delivery and have launched several new mental health care initiatives, including a particular focus on the treatment of PTSD.
We are committed to ensuring that those who suffer, whether it is from physical or mental injuries or illnesses, get the kind of treatment they need from qualified professionals in the field. We continue to dedicate significant resources to the prevention and treatment of PTSD, all of which are accessible to both the reserve and regular forces members.
The documentation that we have previously provided to the committee outlines many of the initiatives, but I would like to take this opportunity to highlight one that we are expanding upon. It is the continued development of the Operational Stress Injuries Social Support Project, in short, OSISS, to create a national support network for injured members, veterans and their families. The first coordinator completed training last March and has set up support centres in Edmonton, Winnipeg, Petawawa and St. John's. We hope to expand across the country over the next several months.
The Ombudsman expressed concerns that coordination between the DND and VAC is poor. While I acknowledge that this was certainly the case in the past, I believe that we have made great strides to fix this problem.
The establishment in April 1999 of a joint DND-VAC Centre for the Support of Injured and Retired Members and Their Families has been an important step in combatting PTSD.
This centre is involved in numerous initiatives and projects relating to the successful transition and care of service personnel from DND to VAC, including the exchange of liaison officer positions to improve communications and coordination, numerous projects to assist in the transfer of Canadian Forces personnel to the care of VAC, commitment of extra funding by DND to VAC to support the numerous programs, and joint participation in the Operational Trauma Support Centres. Both departments have become partners in the OSISS and conduct joint research into health issues, including PTSD. We are developing training and educational opportunities together for both DND and VAC social workers. We are participating jointly in both a mental health and personnel tempo human dimensions of deployment study.
There was also a sentiment that the DND was lagging behind Veterans Affairs with respect to treatment of PTSD. This is clearly not the case, as we are working closely and sharing treatment expertise and resources with Veterans Affairs through the DND-VAC centres, our liaison officers, and initiatives such as OSISS and the OTSCs, the latter being the Operational Trauma Support Centres across the country.
The release of the Ombudsman's report on PTSD issues in February was welcome because it confirmed for us that we are definitely on the right track. However, it also reinforces our belief that we still have a long way to go. We are continuing to build upon the issues put forth in the report.
In this regard, we have developed an action plan to respond to the recommendations in the Ombudsman's report that has been approved by the Chief of the Defence Staff. By the way, our action plan can be made available for your information, if you so wish.
We have accepted all the recommendations outlined in the report. The recommendation involving the establishment of an off-base operational trauma support centre is being studied. In the meantime, we are strengthening our partnership with Veterans Affairs by developing enhanced services at their Sainte-Anne-de-Bellevue Hospital in Montreal for the assessment and treatment of PTSD. This effectively acts as a trial off-site PTSD centre.
Additionally, we have gone beyond the Ombudsman's other recommendation to establish a PTSD coordinator by not only confirming that I will act as the coordinator for PTSD-related issues in the CF, but also by establishing a PTSD steering committee, with representatives from all the primary stakeholders, to review and coordinate all operational stress injury matters, including PTSD.
In addition, we have established a special PTSD adviser position to the Chief of the Defence Staff. Captain Harper will keep the Chief of the Defence Staff apprised of issues regarding PTSD and other operational stress injuries.
The health and welfare of our troops are of the utmost importance to us. We are serious about this, and we will continue to implement programs and activities to deal with it.
Part of the process in improving our capacity to respond is educating our members that operational stress injuries such as PTSD, although not visible, are as real as any physical one and treatable. Obviously, the Ombudsman's report has assisted us in this, but we have more work to do.
In closing, Mr. Chairman, we did not discover PTSD through the Ombudsman's report. In the past few years, we have become increasingly aware that PTSD is out there. We have been investigating its causes and the manner in which it may be treated. Nonetheless, we welcome the report and its recommendations. We are fully committed to taking the necessary steps to look after our service members.
Helping men and women suffering from operational stress injuries is a very demanding task, and we recognize the need to keep improving the services for our soldiers. We welcome the Ombudsman's report and the interest shown by this committee in helping us continue the progress we have made over the last three years.
I believe, Mr. Chairman, I will stop here. With your permission, I will ask Colonel Cameron, the Surgeon General, to given a short medical briefing on PTSD before we take questions.
The Chairman: Thank you, General Couture.
Colonel Scott Cameron, Director of Medical Policy on the Staff of the Director General, Health Services, Department of National Defence: Post-traumatic stress disorder is an abnormality of brain functioning that arises after psychological trauma. Accordingly, it can be thought of as a psychological injury.
While PTSD has been with us for as long as records have been kept, many aspects of this condition have yet to be fully clarified by appropriate research. This can sometimes lead to differences of opinion on certain issues, even amongst mental health experts.
In this presentation, I will briefly summarize for you the currently accepted thinking on this disorder. Before discussing PTSD, I would like to point out that while it is a very serious health issue, it is not the only mental health issue faced by our Canadian Forces personnel. Many other mental, emotional, spiritual and relationship problems can be caused or made worse by the stresses and traumas of military operations. This collection of conditions has been termed ``operational stress injuries.''
There are also a large number of equally legitimate mental health conditions suffered by our CF personnel that are not the result of operations. All of these conditions are potentially subject to the stigmatization referred to in the report. Addressing the mental health needs of our personnel will mean addressing all of them.
[Translation]
The types of psychological trauma that can cause PTSD are generally the result of situations where one believes, rightly or wrongly, that one's life is threatened, for example, combat, natural disasters, terrorist attacks, serious accidents and physical assaults. It is not just the psychological trauma but more particularly the context in which this trauma was produced as well as the interpretation given to it by the victim that together determine the risk the person will suffer from PTSD.
[English]
The exact nature of the process by which PTSD occurs in the brain is not known. However, a variety of brain chemicals have been shown to be present in the brain in abnormal amounts in patients with PTSD. Changes in the size and function of a number of structures in the brain have been shown. The consistency of PTSD symptoms across history, cultures and a variety of psychological traumas, combined with the growing body of evidence of changes to brain and body function in people with PTSD, establish it as a real illness.
The risk of acquiring PTSD after a traumatic event is complex and difficult to determine accurately. The majority of persons exposed to a traumatic event will experience some symptoms compatible with PTSD for a brief time. However, in most of these individuals, the symptoms go away. The percentage of people who go on to develop PTSD following an event is variable, ranging from 5 per cent to 30 per cent.
The symptoms of PTSD are related to the psychological trauma and the emotions experienced around it. They include intrusive thoughts and recollections of the trauma, recurring nightmares, difficulty sleeping, difficulty concentrating, depression, outbursts of anger and persistent high anxiety. The frequency and intensity of these symptoms varies amongst individuals. In some, these can be triggered by an event long after the original psychological trauma.
[Translation]
PTSD is diagnosed based upon specific criteria. The presence of these criteria is established through the answers given to questions either during a meeting with a mental health professional or through a general questionnaire. Even though certain changes in brain and body functions have been noted, there is at present no test available for the study of these changes, which means that PTSD evaluation remains a subjective process.
[English]
The actual incidence of PSTD among our CF personnel returning from military missions is not known and will vary, depending on a multitude of factors. While estimates have varied wildly, most CF mental health experts feel that about 10 per cent of CF members exposed to psychological trauma will go on to develop PTSD. The percentage of members returning from a deployment with PTSD will therefore depend on the frequency and types of traumas experienced on that deployment.
This year, the Canadian Forces will conduct a major research study to accurately determine the numbers of Canadian Forces personnel with PTSD and other mental health problems. This will give us much-needed information on the actual prevalence of the disorder in the Canadian Forces population.
[Translation]
Often, that is to say in roughly 80 per cent of cases, PTSD occurs in combination with a multitude of other psychological problems. These problems can become apparent before or after the onset of PTSD. It is extremely important that all of the problems present in a patient be diagnosed with precision and treated accordingly.
[English]
PTSD is a chronic disease in some people. Some are never able to return to their previous level of functioning. However, many or all of the symptoms of PTSD can be effectively treated, and many patients are able to return to enjoying a normal life.
Most often, a variety of treatments provided by a multi-disciplinary team of caregivers is the most effective way of addressing a patient's needs. Most experts agree that PTSD is best treated as close as possible to the environment where the problem arose, and that the earlier the treatment is started, the more effective it will be. The impression of most experts in the field is that about two-thirds of PTSD patients are significantly improved with proper treatment.
In summary, PTSD is a very real and very serious medical condition. However, it is only one of a number of very real and very serious mental health conditions that can affect our Canadian Forces members.
The brain is the most complex organ in the human body and its connection with body functioning has been well established. The ideas that the brain is somehow immune to illness and that its functioning is under voluntary control are simply implausible. PTSD and other mental health issues are among the most significant health problems currently facing our Canadian Forces personnel.
Adequately addressing these issues is a significant challenge, not only for the Canadian Forces, but Canadian society as a whole. The Canadian Forces health service has been given a clear mandate by the CF leadership to provide our members with the best possible diagnostic and treatment services for these complex problems.
The Chairman: Thank you, Colonel Cameron. Major Grenier, do you have anything you would like to add?
Major Stéphane Grenier, Project Manager — Operational Stress Injury Social Support, Department of National Defence: Not at this point. I am sure there will be questions.
LGen Couture: I will deflect some questions to him.
Senator Day: Colonel, I appreciate your help in differentiating between a syndrome and a disorder. Now we have another one called ``occupational stress injury.'' Is it important for us to start differentiating among these various descriptions that you are giving us, or will that not get us anywhere?
LGen Couture: ``Operational stress injuries'' is not medical terminology. It is a terminology we have invented. In fact, my colleague on my right was a proponent of this terminology. It includes all the mental health injuries our people may be subjected to during the course of their duties. PTSD, being the most prevalent one, is part of that.
One thing I have noted personally over the course of my dealing with this issue is that if people are suffering from any mental health issues as a result of their military service, and it is not considered a real injury but an illness of some sort, it adds to the stigmatization they sometimes experience. I must tell you that it is a real injury, even though it is not visible, like an arm or a leg injury.
We categorize these stress injuries from an operational point of view. When I speak with my doctors, they are much more precise and use medical terminology like ``PTSD,'' or other mental health terms. I hope that helps clarify things.
Senator Day: That is helpful. The broader term you use in a non-medical sense is ``operational stress injuries,'' and they could be emotional, mental or psychological.
LGen Couture: Yes, you are absolutely right.
Senator Day: We talked to the Ombudsman last week. He indicated that, and I do not know if the Colonel had a chance to confirm this or not, upwards of 20 per cent of soldiers who are deployed suffer to some degree from PTSD on their return. Colonel, could you confirm that percentage?
Col Cameron: The truth is, we do not know, and nobody does. That is one area where appropriate research will help us in the future. One of the first important steps in that direction is the study being undertaken this summer in conjunction with Statistics Canada. It will involve a sample of about 8,000 Canadian Forces members, selected by rank and age. The same study is being done in the Canadian population as a whole and in other countries around the world. It will accurately determine how many members, on a percentage basis, are suffering from a variety of mental health problems, including PTSD.
As a medical professional, I shy away from giving a number if I do not know for sure. Everyone has a theory as to what that number is. If you look at people immediately after a psychological trauma, a very significant percentage will have symptoms that are consistent with PTSD. However, if you follow that group over time, the symptoms will resolve themselves in many or most of them. In what percentage those symptoms remain depends on a number of factors.
The most important point is that the percentage is significant, whether it is 5 per cent, 10 per cent or 30 per cent. That percentage represents a significant number of people who require appropriate diagnosis and treatment, and who, if brought back to full functioning and health, represent a tremendous gain for the Canadian Forces.
As to the number itself, there is nobody in the world today who can say they have the right number, and for that reason I think it is deemed less than significant. The reality is that it is a significant percentage. Over the next several years, you will see some studies come to fruition that will establish more clearly what that percentage is. What we do know right now is that it is a significant problem with which we need to deal.
Senator Day: Just to follow up on that, and I do not wish to cross-examine you on this, would you say 20 per cent is an unrealistic figure, or is there some basis for choosing 20 per cent?
Col Cameron: Most people would say the risk of developing PTSD after a psychological trauma depends on several things. One important aspect is the nature and severity of the trauma. Other things include the cultural background of the individuals, how they interpret the trauma, their degree of helplessness in the face of that trauma and so on.
The figure I have most commonly seen is about 10 per cent, as I indicated in my statement.
Senator Day: That is helpful.
General, you indicated that you are setting up a number of operational stress injury social support projects, or OSISS. OASIS would make a nice acronym; we should have put an ``A'' in there.
LGen Couture: We thought of that, but we could not figure out what the ``A'' would mean.
Senator Day: That is peer treatment, and I commend you for the work you are doing. In terms of diagnosis and assessing the problem and getting someone into treatment, two things concern me from what we have discovered thus far in our hearings. One is that this is not the kind of disorder a serving person would like to come forward with in all likelihood, due to comments that it is the end of a career or an indication of a weakness that just does not fit into the image of a strong soldier.
Second, from the point of view of diagnosis and assessment, we are led to understand that the medical facilities, doctors and psychiatrists are not available on many bases. How are you diagnosing and moving these people into the treatment programs you are setting up?
LGen Couture: Let me first address OSISS. It is not a treatment or a diagnostic tool. It is a project that was put together last May to provide social support for people. I will give you the example of Alcoholics Anonymous, where people must support each other to prevent them from returning to their past habits.
We noticed over the last few years that people suffering from operational injuries, or PTSD, felt abandoned or stigmatized. You mentioned it being considered a sign of weakness and of not pulling their weight. That was there, and it is still there, because people did not know what to do about it. They did not know what to expect or what was going on. The first characterization of these people was, ``Well, you are no longer a soldier,'' which is absolutely untrue. They are suffering from injuries that need to be treated.
They were feeling abandoned, and something needed to be done to bring them back into the family. Whenever they were facing an issue that they could not see an end to, someone like them or who understood them needed to be close by to support them.
At the same time, we needed to address the issue of other people within the military unit vis-à-vis these injuries. They needed to be educated and to understand that it is a real injury, not a sign of weakness. People are suffering, and they need to understand that.
The OSISS project has the lead in developing, in partnership with other organizations within the forces, an education program to inform our leaders and our members about PTSD and other operational stress injuries.
We also need to educate people on how to recognize and deal with the symptoms. I personally believe that the best prevention is proper training, unit cohesion, esprit de corps, knowing what the symptoms are and then treating them as quickly as we can after they have been discovered.
That is what the OSISS is all about. It is a group of survivors who have recovered from the injuries and can function. They can provide their assistance and help to others, at the same time as helping me and my colleagues understand what this is all about.
They work in very close collaboration and cooperation with our medical people, who provide not only the diagnosis, but also the treatment. This has to be complementary.
We are taking a holistic approach to this, where the medical world provides the treatment and the social support network provides what I call the ``reintegration into the military community,'' not only for those who are suffering, but also those who will accept them.
Stéphane is a survivor himself, and he came to me with the idea a few months ago. We were looking at what needed to be done. The light came on, and he has been charged with putting that into place. It has paid off already, from my own perspective. I will ask him to add a few words about the OSISS and address the second part of your question, if I may. I hope this clarifies it a little for you, senator.
As I said, we have five operational stress support centres where we do have medical people — a multi-disciplinary team of psychiatrists, psychologists, social workers, chaplains, general practitioners and so on — who work not only to diagnose, but also to provide the treatment. They also provide some education to other people.
We do have five across the country in the major bases of Edmonton, Val Cartier, Halifax, Esquimalt and Ottawa, where there are large concentrations. In other bases, we have medical clinics where general practitioners have access to local civilian specialists if we do not have them on site or within our own resources. However, you are right. In certain places across Canada — and as you know, it is not a problem only for the military — there is a shortage of psychiatrists and psychologists, and sometimes we do have some difficulty finding those specialists. However, in our major areas, I think it is safe to say — although maybe not in numbers — we do have all the specialties that we need to provide the diagnosis and the treatment. We do also send our people to private clinics.
Col Cameron: The market for mental health professionals is very competitive in this country. We have certainly had a policy in the past several years of engaging whoever we can wherever we can. In our larger centres, the OTSSCs, all the disciplines are represented. Some of them are more difficult to find than others.
On the other hand, there is a process at those centres by which the most serious cases are triaged to receive treatment first and so on. It is an ongoing process, and we are continually trying to engage the right kind of professionals. For example, across Canada in the last year and one-half, we engaged 18 additional social workers at our bases outside of the OTSSC initiative.
We are now embarking on a diagnostic program for our people coming back from operations. Experience shows that these symptoms tend to become evident two months after the operation. Now, every person coming back from a military operation — Op Apollo will be the first one — will have an interview with a mental health professional at about that two- to three-month point, preferably with their spouse or significant other, that will include a psychological screening instrument. That may help us to identify these people earlier, because I think the one conventional wisdom is that the earlier we can identify these problems, the better our chance. These are treatable problems if identified early.
Maj Grenier: We have covered most of what OSISS is all about. The only thing I could add is that this project was put together by survivors, for survivors, and it is working pretty well. These guys are very strong. They are already providing ``connectivity,'' I guess, between the units and the medical field. We have seen that. We launched the project on March 1, and we have already reconnected about 90 people to the system, whether through the medical system or disability insurance. We are only one month old.
There is a definite need for soldiers to talk to one of their own, to connect back to the system, and to see that it is not abandoning them. OSISS is that strength. We are employing survivors, people from the mid-1990s who have been through it, and we are hoping that soldiers of the future will not have to go through what we went through.
The department is fixing a lot of things. We want to give hope. We need to give hope to these guys, and it is working.
LGen Couture: If I may add one last comment on your very important question, our goal in all this is to treat the people and put them back on their feet so they can function properly within their unit, because they are valuable assets.
Some of our people are suffering more than others. At some point, they may not be able to get back on their feet and function properly within the military unit. We will have to separate them, and that is where the Veterans Affairs-DND connection is most important — to ensure that the transition from military to civilian life is properly managed by Veterans Affairs Canada and all the other programs.
Our goal is to bring them back within the military into a functioning operation.
A soldier who has suffered an injury is not less of a soldier. He might not be as functioning as before, but he is still a soldier.
Senator Day: I have one supplementary question for Colonel Cameron. I am still concerned about this 10 per cent to 20 per cent. Did I understand you to say that you are implementing a program whereby all soldiers returning from deployment will put through a psychological assessment? In that way, you will be able to detect this early so that it can be treated more rapidly?
Col Cameron: That is correct. At the end of the day, as I indicated in my remarks and as Major Grenier said, it is a big step for people to identify with this. Finding ways to make it more acceptable and easier for the individual is a difficult challenge and involves many steps.
One of those steps is to give them that private forum, if you will, with a mental health professional so that they can frankly discuss these issues. They should at least be given that opportunity. We are hopeful that that will help.
Senator Day: Thank you both. I commend you for your work.
Senator Kenny: I have a supplementary question for Lieutenant-General Couture. Major Grenier mentioned several times that the programs were working well. What criteria do you use to measure that?
LGen Couture: I examine injured soldiers back in their unit line. Once soldiers have returned, that is progress. The number of people to be diagnosed, or at least to see our medical practitioners, has increased over the last few years. The number of people within the chain of command, from the lowest to the highest, with a better understanding of personal stress injuries and post-traumatic stress disorder has increased. I examine for that.
Senator Kenny: That is a very vague answer. Surely you could provide us with better and more specific indices. There must be measurements, records and ways that you use to determine the cost, how many people are coming back and at what level.
LGen Couture: Yes, I did not understand that you wanted specific numbers.
Senator Kenny: I do not want specific numbers so much as I want to know your methodology for determining whether it is working well. You basically said that it feels good, so it is working. I would like you to tell me in more detail how you arrive at that conclusion.
The Chairman: You might also put it into the context of how long statistics have been kept. Our understanding is that that only began quite recently.
LGen Couture: You are right. We are putting information systems in place to capture those statistics so that we will have a much better measurement.
As was mentioned after the previous question, we do not know the specific number of people suffering from this. We are preparing a mental health survey this year that will give us a benchmark on which to base an exact measurement of the improvement or the decline, whichever is the case.
We know exactly how much money we are investing in the system and the number of people in our clinics. I do not have the numbers at hand now, but we have been recording these figures recently. We felt that we needed a system to properly evaluate the appropriateness of our efforts.
We have had feedback from patients and from surveys. On the medical side, Colonel Cameron has had some feedback as well.
Col Cameron: Yes, sir. I am guessing that the question speaks to performance measurement in health care.
Senator Kenny: Yes. What are the indices of improvement?
Col Cameron: As you know, this is an evolving area in all aspects of health care in Canada. Canadian Forces health service is in the middle of a complete reform of the whole system from end to end. A large part of that reform is in the area of management, and will include instituting reliable, reproducible performance measures of all aspects of our health care system, including mental health.
Right now, we do not have many statistics about, for example, the percentage of people who return to duty. We know that is a weakness in our system and we are spending time and money to fix it. It will be fixed within the next several years. In particular, there are some things being instituted immediately in the area of operational stress injury to try to collect some data quickly by gathering the information on paper.
We have had, for example, a program of what we call ``staff assistance visits,'' or inspections, of our various Operational Trauma and Stress Support Centres, OTSSCs. We have another round of those inspections in 2003 to ensure that we are providing a uniform standard of diagnosis and treatment that conforms to the best practices of health care in Canada.
There is also a working group within the OTSSCs developing an appropriate set of acceptable and defensible measures to show the public and the people whom we serve that the program is effective. That will be in keeping with what will happen within our Canadian Forces health care system over the next several years.
Senator Banks: Thank you for appearing before the committee, gentlemen. When Colonel Cameron was describing symptoms, I was reminded of having felt exactly that way when I was doing my income tax the other night.
I commend you for the fact that you now seem to have a handle on this issue and that you are actually doing something about it. Is this what would, 50 years ago, been called ``shell shock'' and terms even more disdainful and disrespectful, one assumes? It is sad that it has taken until now for us to begin to understand it.
Lieutenant-General, you mentioned the word ``stigmatization'' and how important it is to educate people in order to reduce that. I know that when it was called ``shell shock'' and other awful things, and we did not know what it was, the stigma began in the line. One did not want to admit to whatever it was then called. The most important issue, it seems to me, would be that first admission to my buddies — to the guys in my crew — that I needed help or that I was going to someone for help, and then having the word leak out to the people I work with every day.
I ask about this because I knew several people in the late 1940s and 1950s who went through that, and it was hell for them.
I know that you do not yet have a specific measurement, but how successful do you think you are in educating people so that they understand that this is not even an illness, but an injury? Are we beginning to make some headway?
LGen Couture: What you refer to as ``shell shock'' is today known as PTSD, and it goes even further back than that.
In the Canadian Forces, we rediscovered PTSD, or mental health injuries, in the mid-1990s. We have been at peace since the Korean War. There were not many activities in the Cold War era that would induce these kinds of injuries. The peacekeeping missions we undertook did not present the same challenges and the same dramatic scenes that we saw in the Balkans.
Senator Banks: People who suffered from that were still around.
LGen Couture: Absolutely. I am addressing your question about education.
When we first saw this, we did not know what it was, so we started learning ourselves and then educating our people. Obviously, the education we provided was not effective, because there are still people today who do not understand that this is an injury and victims have been ostracized and stigmatized. We need to effect a cultural change.
Therefore, we are evaluating, from an educational perspective, what is currently being done to determine where it is not effective, where we need to change it and how to do that. This is presently ongoing.
The leaders of the Canadian Forces and those who are dealing with this issue firmly believe that knowledge of this injury is key to helping those suffering from it to recover. The victims must accept that they are injured and must not be afraid to come forward. Those who are around them need to understand this injury and offer help. The leaders need to be able to recognize the symptoms and to direct the individual to medical help.
We need to introduce better education and knowledge into our leadership courses at all levels. We currently have a component in the leadership courses, but it is obviously not enough, because I still hear it said that PTSD does not exist, or it is not recognized.
The Operational Stress Injury Social Support division has been given the mandate to examine all the educational packages and determine what works, what does not and what needs to be done.
I said earlier that the best prevention is proper mission training, unit cohesion and recognition of the symptoms. There must be training on operational stress injuries during preparatory training before deploying for an operation — the risk, the impact, the effect, the symptoms and so on — and the leaders must be reminded of their responsibilities in this.
Senator Banks: Does the basic training of infantry personnel include instruction that physical and mental injuries are equally recognized?
LGen Couture: Currently, they are instructed about physical injuries. There is insufficient instruction about mental injuries.
Senator Banks: Would it not be a good idea to start there?
LGen Couture: There must be education at all levels. Everyone in uniform needs to know about this. You are absolutely right that the best place to start is at recruit school. Although there is currently some training at that level, I do not think it is sufficient. We are looking into it.
Senator Banks: Can you fix it?
LGen Couture: Yes.
Senator Banks: You are going to conduct a survey that will involve 8,000 regular service members and 5,000 reservists. Trained people from Statistics Canada will conduct the 90-minute interviews to determine histories, et cetera. How many people from Statistics Canada know how to recognize the symptoms of this kind of injury?
LGen Couture: I cannot answer that. I am told the survey has been constructed in such a way that competent people will interpret the results. That is all I can say because I am neither a statistician nor an expert in surveys.
Col Cameron: The interviewers will be specifically trained in the administration and interpretation of the responses and the interviews will be confidential. As I mentioned in my remarks, this study is not just a Canadian Forces study; it is part of a larger study across Canada. Canadian Forces people will not be conducting the interviews, so having adequate numbers of interviewers is not an issue. I do not know how many interviewers will be assigned to the Canadian Forces part of the survey. We can get that number for you, if you would like, but adequacy of training for the interviewers is not an issue. I think we can safely assume that they will be appropriately trained.
Senator Banks: Do you know how long it will take to get the initial survey results?
Col Cameron: The data collection is scheduled to start in a couple of weeks and run until this December. The study sample comes from a representative group of people of varying ages and ranks, et cetera. The sample was randomly selected from within those groups. To find those people and arrange interviews is fairly complicated logistically.
Senator Banks: To interview 13,000 people for 90 minutes will take 20,000 hours. That is approximately three years, going 24 hours a day with no time for lunch.
Col Cameron: There are a fair number of interviewers. It is my understanding that they have identified 13,000 names, but that the sample size will be 8,000, given that they will not be able to locate everyone. Also, the interview may take a little less than 90 minutes to conduct.
It is unquestionably a big undertaking and I think it will give us some very good information.
Senator Banks: A peer coordinator training session took place in Mississauga between February 18 and March 1 this year.
Are you running into resistance in establishing those kinds of initiatives? This is sort of related to OSISS, is it not? It is support level training.
LGen Couture: Yes, it is OSISS.
Senator Banks: My overall reaction to what you are saying here today is — terrific. It should have happened a long time ago, but you are doing it now, thank goodness. Why are we going at this gradually? You are saying, ``We did one in Mississauga in February.'' Is there some resistance from within? Why can you not just forge ahead? We know we need this, we know this is real — we have known that for about 50 years — and now we need to do something about it. Are you meeting resistance somewhere?
LGen Couture: The course was conducted in Mississauga for a specific reason. I will ask Major Grenier to answer because he was running it. There is always some resistance. When we implement something new like this, we are charting new ground.
I have not seen any resistance from the senior leadership of the force. They are extremely supportive and tell us to go for it. Yes, there is some resistance at the lower level. We need to educate the people.
Why are we setting out in this way? First of all, we need to identify the peer coordinators and train them. We need to take care of them too, because they are survivors. We want to do it right, so we are moving at a slower pace with a type of pilot project. We have implemented this thus far in Newfoundland, Edmonton, Winnipeg and Petawawa. We will have an evaluation of this project by the fall, and based on the results, we will make any necessary adjustments and then flesh it out after that. We want to be sure that we are doing the right thing and that we are doing it properly. I would like to see it move faster, but I cannot make it happen any faster because of the people involved. It is not a matter of money and resources. I have all the money that I need for that project. It is the people — finding them, training them and so on.
Maj Grenier: One important issue to note here is that it is a very dangerous business to get into. I recognize that, as do my colleagues in the peer support coordinator role.
Senator Banks: Dangerous in what way?
Maj Grenier: Dangerous in the sense that it does not follow traditional methods. I am a patient and see a therapist every week. It is very non-traditional to put the care of individuals in the hands of patients, that is, people who, to a certain degree, suffer from the same thing they do. Therefore, the last thing I want to do is put my colleagues in harm's way without first evaluating the potential of this.
Perhaps this can shed a little light on the earlier question about how well is it going. We are building a database. We have been collecting data and monitoring how our guys are doing from the day we started.
Veterans Affairs is getting highly involved in validating and evaluating the success of this program. I would rather take baby steps first to make sure that I am not wrong. If we are wrong, we cannot continue. I cannot put veterans in harm's way, in a sense, if this does not have the potential to work.
We do not have data right now to show you, but I can report that it is working very well so far. This is why we are doing it this way. We will conduct a pilot project for nine months, then see how it is going and expand from there.
Senator Banks: You used the word ``subjective'' when you were referring to diagnosis. Is that still true? Is there any hope of achieving an objective diagnosis?
Col Cameron: I think you have to appreciate the context in which I use the word ``subjective,'' and that is it is not based on doing a scan or measuring someone's serum PTSD level. There are objective criteria, if you will. Mr. Morin referred to them last week. Certainly, the criteria by which PTSD is diagnosed are well established. It is just that the interviewer's interpretation of someone's responses establishes the diagnosis as opposed to a —
Senator Banks: Interviewer A will ask the same questions and arrive at the same conclusion as interviewer B, give or take a nickel.
Col Cameron: Give or take a nickel. I cannot say that happens in every case.
Senator Kenny: Most of the discussion tonight has been on treatment and education to change the culture so that, first, folks can identify the problem, and second, treat it as an injury and not as something unattractive.
Could you elaborate more on the preventive side? It seems to me that preventive medicine is the least costly and best way to proceed. What changes in military doctrine are needed to diminish the likelihood of this happening? What must be done differently within units operating in the normal course of events so that people do not receive this sort of injury?
LGen Couture: I will ask my doctor to talk about prevention from a medical point of view. I said at the beginning that the best way of preventing it is proper unit training, unit cohesion, sound leadership and then education.
Senator Kenny: If I can interrupt, what does ``proper unit training'' mean? I assume you are doing proper unit training now. What different kinds of unit training are you talking about?
LGen Couture: Training that focuses on the mission. Training that is as realistic as possible, which we do now. I am not saying that we are not doing proper training. On the contrary, I am saying that when people are ready to deploy and operate in collective sense and know individually what they have to do, it creates better unit cohesion. With better unit cohesion, people look after each other. We also need to effect a cultural change.
Senator Kenny: If I could stop you there for a minute. I would like to follow you step by step as you are going through this. Could you describe unit cohesion now? Ten years from now, what difference would you see if you had an effective program? In other words, I do not understand words like ``better'' because I do not know what kind of change that means.
LGen Couture: I work in the personnel world and have been away from training for a long time. However, when you prepare a unit for a mission, you first need to do a detailed analysis of what that mission is all about and what needs to be accomplished. Then you train them, step by step, to accomplish that mission, starting at the lower level, and you achieve success when you instil confidence in the troops that they can do the job.
This was how it was done many years ago. It will still be done the same way in a few years' time, because that is the only way you can prepare troops for combat or other operations. Any aspect that reinforces unit cohesion will remain the same.
We have rediscovered issues such as PTSD as we have moved along. Our forefathers in the Second World War knew what it was all about, but we did not live through that in the 1970s, 1980s and early 1990s.
We had to relearn how to deal with it. It has to be injected into the individual training and then into the unit training. It must be supported by a proper medical system, social support network and transition package.
Senator Kenny: I am having difficulty with the responses. I do not understand words like ``proper'' or ``better'' or whatever. I do not follow, General. I hear what you are saying. I know what the words mean. If I walked out of this room and someone said to me, ``Okay. What is the army doing now to change its training so that there will be a lower incidence of this,'' I would say, ``Well, they will do things better.'' That is the best answer I would be able to give right now.
I would like you to help me. I do not know whether other members of the committee are confused. I am certainly confused, because at this point, I do not have a clue about how army training will change over the next 10 years to prevent or lessen the incidence of this.
The Chairman: Maybe in due course, Colonel Cameron could help by indicating whether there is any data on what type of individual is more likely to suffer from this injury and what causes it. If we knew that, presumably we could take steps to either avoid having that person come into contact with the cause or find some other solution to the problem.
I think we are having difficulty because it is obviously an area about which we do not have a great deal of hard data, from what I am hearing. We have some anecdotal evidence. We have some medical criteria. However, there are a lot of grey areas. I am neither a doctor nor a soldier. I think your question is very well put, Senator Kenny.
Senator Kenny: If there is this vagueness, I do not know why there is so much optimism. I need something a little more specific than I have been hearing so far today to be optimistic.
The Chairman: Do you understand, as I think I understand, Senator Kenny's query? When we step out of this room, we will be asked, ``What is the army doing differently now?''
LGen Couture: I think I missed the meaning of Senator Kenny's question.
We need to ask the army exactly what they are doing. I am with the personnel organization, not the army. I am telling you what I would do. Stéphane, do you want to add something on what we discussed the other day?
Maj Grenier: I have talked about the vision of many veterans. I ran it by Korean vets, World War II vets, some Vietnam vets and a lot of younger vets of our generation. General Couture approved what is now a vision from the training perspective. It can help with where I would like to see the Canadian Forces go. It is in the realm of very tangible coping skills for our soldiers.
When I was sleepless at night in Rwanda, I did not know what was happening to me. My colleagues did not know what was happening to me. Nor did I know what was happening to my colleagues.
Doctors can confirm that the sooner you get someone into treatment, the more likely it is that it will be successful. If you wait seven years, like I did, then perhaps treatment will not work as well.
The point of my comment here is that my vision, our vision, is to try to provide more coping skills. How will we do that? How do you teach an infantry corporal, a section commander, to be more aware of what is going on in his soldiers' heads after being shelled? That is what we need to teach. Are we there yet? Of course not. OSISS will try to help develop that. Why? Because we now have this network of, not World War II vets, unfortunately, but Vietnam vets, all the way to East Timor vets. Some guys who have come back from Afghanistan are already joining this network.
We are bringing to this a pragmatic, practical approach to what the soldiers felt was needed. We are in the needs analysis now. I am talking to former corporals and infantry people. We are developing what was lacking in all of this in order to make recommendations to the army. However, we are certainly not at that stage yet.
In 10 years from now, we hope that our soldiers will be able to deal with the threat of stress the same way we deal with the threat of cold. We can do this by recognizing the symptoms early on and having some kind of buddy system whereby people do not have to fester alone in the theatre, and after coming back, they will certainly not wait five to seven years to seek treatment the way I did.
From what we know, this is certainly worthwhile exploring. That is where OSISS is trying to go. This is a moving, living, breathing project. It is certainly the track we are on right now.
Senator Kenny: Colonel, from a medical point of view, are there things that can be done in training that are not being done now that will reduce the risk of this happening?
Col Cameron: As you probably know, you cannot open a journal or a book right now and pull out an evidence- based strategy for the prevention of PTSD. There is evidence in the literature that better unit cohesion does seem to reduce the incidence.
Before I get any deeper into this, our director of mental health for the Canadian Forces is with us. I think he could probably more accurately answer your question on what is currently in the literature.
Colonel Randy Boddam is a Canadian Forces psychiatrist.
Colonel Randall Boddam, Director of Mental Health Services, Canadian Forces Base Borden, Department of National Defence: The only way to prevent PTSD is to prevent exposure to trauma. That is the point. We cannot have an armed force in which personnel will not be potentially exposed to trauma.
As Colonel Cameron was starting to indicate, based on our understanding historically, and looking at what is happening in places like Israel and other nations that are regularly exposed to traumas, there seem to be some mitigating or protective factors. However, no protection is 100 per cent effective. I think that has to be the starting point.
One of the factors that seem to be most important is looking at whether the person has a past psychiatric history. In saying that, people with previous psychiatric disorders or illnesses can be exposed to trauma and not develop PTSD. Not everyone who develops PTSD, or other stress injuries such as combat stress reaction, adjustment disorders and so on, has a past history.
In terms of unit functioning and the type and nature of the mission, as General Couture was starting to identify, people's understanding of their task and their capacity to discharge their duties is very important. Putting people in an environment in which they feel helpless or unable to accomplish that task is a recipe for disaster. That is an extreme. I am not suggesting we do that, but it is a factor. Therefore the nature of the mission is important.
The affiliation or affinity of the leadership and the unit for that task is equally important, for the same sorts of reasons.
We, and our allies, for example, the Americans, have identified the capacity of the individual — and I think this is what Major Grenier was starting to talk about — to recognize and utilize self-help behaviours as a very important process. In fact, as part of the medical services restructuring that Colonel Cameron was talking about, we are undertaking to teach people stress management and coping strategies.
Therefore, when they are placed in a stressful situation, they will have some very basic self-aid techniques that they can use.
Physical fitness is also a very important factor for several different reasons, in addition to dealing with the physical rigours and therefore response to stress. It can also teach people that they have the capacity to deal with stressful situations. The ability to communicate is very important. We use the term ``unit cohesion.'' What does it mean? There is some very good evidence, not just within militaries but also within organizations such as firefighters, that if you have the feeling that you are working with a group of people who support you and whom you support, people you can talk to and be vulnerable with, your ability to mitigate stressful situations is enhanced. It is these sorts of things that are important.
Senator Kenny: We have just heard a list of some of the indicators from the colonel. How will the training program change to incorporate dealing with those issues? What will we be different a decade from now that will take into account the factors that the psychiatrist has just listed?
LGen Couture: I do not think my crystal ball sees 10 years ahead, but I can tell you now that I have asked the OSISS group to examine, while we do train people to become stronger physically and able to cope with physical demands, how do we train them to be stronger mentally? Is there some activity or exercise that we can do to enhance mental resistance and learn how to cope with this kind of stuff? I have not had an answer yet. We are aware of the point that the doctor has mentioned, but we need to determine exactly how to develop the same kind of ``exercise program,'' if you will allow me that expression, as we do for physical fitness. I do not have the answer, but we are looking into that matter.
Senator Kenny: I have trouble with this testimony, Mr. Chairman. For example, my understanding is that physical requirements in the Armed Forces are declining, not increasing. My understanding is that the standards for the physical tests are being lowered rather than raised. The witness says that is not true, therefore I would like to have documentation to demonstrate that. I would be happy to see that.
However, I do not understand how you can come before us, or why you are coming before us, without being able to specifically articulate the connection between the problem that is being described by the major, the factors that have been enumerated by the colonel, and how this will fall out in terms of doing things differently, if it is possible, to protect people from these things.
It seems to me that it is really important to take care of the people who have been injured now. I think that is terrific, and it seems to be much of what the network is about. However, we are looking at the next generation, the next decade, and if you do not want to look out 10 years you can look out 5. What are the plans for making things different? I do not hear much.
LGen Couture: Senator, I am sorry but I do not know what would satisfy you. If you want to see a detailed syllabus of a training plan, I do not have one with me. I cannot show that to you. I am saying that all that we have learned about operational stress injuries is being integrated into the training of our people. We need to look at how this evolved over time.
Also, I have asked my education specialist and my training specialist about how to develop a program to enhance people's resistance to this, and all the factors that the doctor has mentioned are being incorporated into that study. When I have that answer, I will be able to write a detailed syllabus.
Yes, our people's ability to face those situations needs to be improved. I agree with you. For example, we must make sure they have proper physical training, the proper equipment and the proper combat training for their assigned mission. We must make sure they have all the information they need and are well led. These factors all contribute to diminishing the likelihood of those injuries.
That will not eliminate our problem completely. I do not think we will ever do that, although I dream of being able to do so. However, many things are being done that will have an impact. I do not have any statistics to show that mission X had X number of injuries and mission Y had a different number. I wish I could provide you with those, but I cannot at this time.
We are examining every aspect of military training for personnel that are about to deploy on a mission, and keeping in mind every hazard that we must face, including the trauma that was referred to. We are learning as we move along and we are improving. What works is kept and what does not is shed. I am sorry that I cannot provide you with a detailed, line-by-line training plan. It seems that is what you would like.
Senator Kenny: No, I would like to have some better understanding of how the issues that the colonel described are transmitted to Saint-Jean or Gagetown, or wherever training takes place, and how the trainers incorporate it into their work. I am not particularly interested in a detailed syllabus. I am interested in whether there is a process underway to do it and whether there are criteria in place to measure that. I am not very comforted when it is said that things are being improved when we do not have criteria to measure that improvement. I would sooner you said you do not know yet and you will find out if things are being improved because you will measure it this way, and if those measurements do not work, then you will try it that way. I do not see the connections.
LGen Couture: I have to apologize; I think I missed your point totally. Now I understand your question.
I said earlier, in answering some of the questions, that we do have information — I call it ``information'' at the moment because I am convinced it is not sufficient — at the recruit level on mental health injuries. We do have some education and training aspects in the leadership courses at the schools in Gagetown and Borden. The Royal Military College of Canada psychology department runs a few courses on the issue, but I am saying it is not good enough because it does not make the changes that we think are needed to address those issues. We are analyzing the content of the information being provided to the troops in Saint-Jean, Gagetown and Borden.
We are looking at how we can make it better. A multidisciplinary team is doing what we call a ``needs analysis'' of what must be covered in the training over and above what we are doing right now. We incorporate the people from the OTSSCs, the psychiatrists, the psychologists, the specialists and the like.
Every OTSSC has what is called a ``reaching-out team'' that can be sent to any base in Canada that needs some kind of education delivered by a specialist. We can talk about that. That is what we are doing right now. That is what we need to work and improve, particularly at the school in Saint-Jean and the leadership school.
That is what I am doing. It took me a long time to answer, but I did not understand what you were getting at. Is my understanding of your question correct?
Senator Kenny: Yes, you answered my question, thank you.
The Chairman: To what extent are we monitoring the practices of other countries, principally the NATO countries, in dealing with this problem?
Col Cameron: NATO has a number of working groups in various subspecialty areas of medicine and we participate in those. Colonel Boddam is a member of the working group dealing with mental health issues.
In addition, there is extensive and ongoing liaison among subject matter experts. In the past year and a half, Colonel Boddam has visited several countries and liased with their specialists working in this area.
There is fairly extensive literature published by predominantly military medical experts, but also other medical experts, dealing with these questions. The process of information sharing on the medical, diagnostic and treatment side is quite extensive.
The Chairman: Would you be frank about ranking our efforts? Are we in the middle of the pack, leading the pack or at the back of the pack?
Col Cameron: Colonel Boddam is directly involved in that work and I would refer that question to him.
Col Boddam: We are number one, of course.
The Chairman: What is your frank assessment?
Col Boddam: In many respects, we are probably leading the pack. We chaired the working group in Ottawa in 1999. We brought in an expert from the United States and had a frank discussion about the treatment of PTSD. It was interesting to see that different countries had different approaches, from less acceptance that this is a true disorder to, yes, absolutely, this is a very important disorder. In the three years since then, most people have come to realize that this is a significant disorder that has an impact on our forces.
As I speak with other people about what we do and frequently make presentations at that working group, I receive feedback that we are certainly on-line with what others are doing. We give advice to other people.
I would love to say we are number one. I do not know that we are necessarily, but we are on the plus side of the curve.
The Chairman: General Couture, did I hear you say that of the Ombudsman's 31 recommendations, you expect to have successfully dealt with them all, or are working on them all, or have accepted them all, with the possible exception of the OTSSC site being on-base or off-base?
LGen Couture: I would not use the past tense, as you have. We are dealing with this. We have accepted all recommendations. We are working on them all and putting in place a plan to address specific and broader issues.
There are two differences. The first is the OTSSC off-base. We need to study in detail how we would address that. We do not wish to close a facility on one base that is well established and move it to another, because that would be counterproductive. That would further stigmatize our people and they might believe that they were in a different category.
In the meantime, we are dealing with Veterans Affairs Canada in regard to Sainte-Anne-de-Belleview Hospital in Montreal, where they are seeing some of our patients on an outpatient basis.
The medical services are studying those recommendations to determine how we should do that and what kind of base we would be looking at. I cannot tell you where we are in the study right now, but that process is ongoing.
The Ombudsman recommended there be a PTSD coordinator, an individual who would report directly to the Chief of Defence Staff and who would keep track of everything to do with PTSD. We went beyond that recommendation. The Ombudsman talked about the coordination of PTSD treatment, health care, compensation benefits, family support, education, individual training and so forth. Those aspects fall within my field of responsibility.
We have created a steering committee that I will chair and which will include the second in command of the army, navy and air force and all the principals responsible for education policy and health service delivery. Colonel Boddam is an adviser. We will pursue a holistic approach. Having senior leadership from the army, navy and air force present at that table will facilitate the implementation of the report.
In addition to that, CDS has appointed a PTSD adviser, an officer of the rank of captain of the navy, who reports directly to the Chief of Defence Staff and will advise on the evolution towards not only the implementation of the report's recommendations, but also the treatment of PTSD.
The Chairman: We heard some testimony about the difficulties that someone can encounter who is discharged for a disciplinary or non-medical reason when subsequently it is ascertained that that person was suffering from PSTD. How do they then go about getting a medical discharge? Are you working on that?
LGen Couture: When someone has been discharged and the medical review is done after the fact, and it is discovered that the discharge should not have been for administrative but rather medical reasons, we do make that change. Some recent files have been changed.
I do not know if you are referring to a specific case, but procedures and policy are in place so that the reason indicated can be changed if it is demonstrated that it was not appropriate. We have changed that in the past from a 4-A to a 3-B. It is a long process, but it is possible to do it.
Senator Banks: Following on from what the chairman just asked, if I am moving from the service into civilian life, but not as a result of disciplinary action, I am now moving into the VA administration, I presume. How much of a bump do I feel? I am going to lose you?
Do you continue on with me, if you were my doctor?
LGen Couture: If it is PTSD, yes.
Senator Banks: How much of a bump is it?
LGen Couture: It was a huge bump. We are trying to lower it as much as we can and make it seem smaller.
Before you are released from the Forces for medical reasons, you enter a rehabilitation program. That program would allow you to perhaps be re-educated in a field where you could get work and make a decent living. You will be transferred to the care of Veterans Affairs through the case managers and transition coordinators that we have on some of our major bases in Canada.
If you are PTSD sufferer, there is an arrangement by which you could still see the same doctors. It is not perfect yet, but if you compare what we do today to what we did five years ago, the difference is like day and night.
Senator Banks: If I have a spinal injury, not PTSD, but a physical injury, do I get the same level of care from VA administration?
LGen Couture: From my perspective, yes.
Col Cameron: The first thing that you must remember is that if you have a spinal injury, you will be looked after in a very sophisticated tertiary care facility. The doctors looking after you will not be Canadian Forces physicians. They will be civilian specialist physicians. When you transit from the Canadian Forces to the civilian world—
Senator Banks: I get the same level of care?
Col Cameron: You will have the same doctor because Veterans Affairs does not have those doctors either. The difference is that the benefits plan will change from that of the Canadian Forces to the Veterans Affairs benefits plan.
Senator Banks: Do they provide the same level of service, at least ostensibly?
Col Cameron: Yes, would be the best way to answer that question. In some ways, the benefits that they offer are greater than those we offer. There has been a fairly extensive initiative over the last several years to try to harmonize the benefits that people receive.
I think that your question was in the specific context of people moving through the OTSSC. There is a very extensive initiative to try to eliminate that ``bump'' by mirroring the services. OTSSCs are ``co-staffed,'' if you will, so that you continue to see the same care provider.
There is something of a myth that people in this country have one doctor. I think you would all agree that people have many doctors, depending on their particular problem.
LGen Couture: If you are an ex-serviceman and you run into difficulty, you call the VAC centre and we will help you.
Senator Colin Kenny (The Acting Chair) in the Chair.
Senator Kenny: I would like to extend apologies on behalf of Senator Meighen. He had to leave the chair to catch a flight. He did not anticipate that we would be so interested in what you had to say tonight, and the meeting has run a little longer than expected.
On behalf of Senator Meighen and the Subcommittee on Veterans Affairs, I would like to thank you gentlemen for the work you have done and for taking the time to come and explain what you are doing and the direction in which you are heading.
The committee adjourned.